AUTISMASHRAF TANTAWYProfessor of Psychiatry Suez Canal University Ismailia, Egypt.
A Complex Developmental Disability.The Most severe neuropsychiatric condition inchildhood.Autism first described by Kanner (1943).Typically appears during the first threeyears of life.Triad of impairments: 1- Socialization. 2- Communication. 3- Imagination.
Autistic DisorderICD-10 & DSM-IV-TR1) Social Interactions Impairment: Nonverbal Behaviors: Gestures. Peer Relationships. Spontaneous Sharing. Reciprocity. Joint Attention. Eye Contact: Poor or Avoidant. Making the Connection.
Autistic Disorder ICD-10 & DSM-IV-TR2) Communication Impairment: Spoken Language. Abnormal Prosody of Speech. Idiosyncratic Words. Initiate or Sustain Conversation. Stereotyped Language. Making Social Play.
Autistic Disorder ICD-10 & DSM-IV-TR3) Restricted, Repetitive & StereotypedBehavior, Interests or Activities: Intense Preoccupations. Inflexible Routines or Rituals. Stereotyped Motor Mannerisms. Preoccupation with Parts of Objects. Getting Stuck.
Red Flags… NICHD suggests doctors consider an evaluation if: The child does not respond to his/ her name. The child cannot explain what he/ she wants. Language skills or speech are delayed. The child doesn’t follow directions. At times, the child seems to be deaf. The child seems to hear sometimes but not others. The child seems to be in his/ her “own world.” The child is not interested in other children. The child walks on his/ her toes. The child shows unusual attachments to toys or objects. The child spends a lot of time lining things up or putting things in a certain order.
Red Flags continued… The child doesn’t point or wave bye-bye. The child used to say a few words but now he/ she doesn’t. The child throws intense or violent tantrums. The child has odd movement patterns. The child is hyperactive, uncooperative or oppositional. The child doesn’t know how to play with toys. The child doesn’t smile when smiled at. The child has poor eye contact. The child gets “stuck” on things over & over & can’t move on to other things. The child seems to prefer to play alone. The child gets things for him/ herself only. The child is very independent for his/ her age.
Prevalence of Autism2-6 cases per 1,000.Boy : Girl = 4:1.Usually identified before 36 months.No racial or socioeconomic differences.
Important Roles of Primary Care Physicians/Medical HomeEarly recognition:– Knowledge of signs & symptoms.– Developmental surveillance & screening.Guiding families to diagnostic resources &intervention services.Conducting a medical evaluation.Providing ongoing health care.Supporting & educating families.
Screening in Primary CareSurveillance for Social &Communication skills.Screen at 18 & 24 months withspecific screening test.Reassess at well child visits(Diagnosis for children with highfunctioning ASD).
ASD Screening in Primary CareChildren at Higher Risk:– Siblings of children with ASD: 10 x increased risk.– Premature Infants.– Comorbid Genetic Syndromes: e.g. Fragile X syndrome, Tuberous Sclerosis.– Prenatal Exposures e.g. Valporic acid.Regression in Milestones: 25-30%.– 15-24 months of age.– Change in language, social awareness or behavior.
Diagnostic EvaluationApplication ICD 10 or DSM IV TR Criteria:– History.– Observational Measure.Medical & Physical History:– Behavioral History.– Family History: Genetic risk factors.Assessment includes: IQ, Speech, Language,Adaption, Motor, Social, Emotional &Hearing.Assessment of Parents: Understanding, CopingSkills & Resources.
Diagnosing Tests for AutismSeveral tests have been developed that arenow used in diagnosing autism:– CARS: Childhood Autism Rating Scale.– CHAT: Checklist for Autism in Toddlers.– ASQ: The Autism Screening Questionnaire.– STA: Screening Test for Autism in 2 Yrs.
Medical Work UpGenetic Testing Karyotype: 5%. Microarray: 6-27%. Fragile X: 1-2%. MeCP2 FISH Chr 15: 1%.Metabolic Testing Amino Acids-<1% Organic Acids<1%Neuroimaging MRI, any lesion-up to 48%EEG Any abnormality-16-68% Seizures- 25% lifetimeOther Low Lead.
ManagementGoals:– Minimize core & associated deficits.– Maximize functional independence & QOL.– Alleviate family stress.Educational Intervention.Developmental Therapies:– Communication.– Sensory, Fine Motor & Gross Motor.Behaviorally Based Treatments:– Core & associated symptoms.– Social Skills.Medical Treatments.
Medical ManagementTreatment of Coexisting Problems:Epilepsy, Behavior & Sleep disorders.Medication Management For:Inattention, Impulsivity, Irritability &Aggression.
Medical ManagementComorbid Symptoms or ConditionsHigh rates of co-morbidity Tic Disorders (10%). Seizures (25%). ADHD (30-75%). Affective Disorders (25-40%). – e.g., Depression or Anxiety . – Higher in Asperger’s. GI Problems (10-60%). Sleep Disturbance (50-75%). Challenging Behaviors (10-35%).
Nutrition In AutismFood Sensitivities: Psychoactive peptides fromimproperly digested casein (milk) or gluten-based (wheat) foods affect brain function insome autistics.Gluten-Free Diet Suggestions:– Instead of wheat flour, use potato, rice, soy or bean flour.– Red meat, fish, rice, fruits, beans, nuts, seeds & vegetables do not contain gluten.– Avoid all foods that contain wheat, oats, pasta, cereal & many processed foods.
Nutrition In AutismCasein-Free Diet Suggestions:– Instead of cows milk, use rice or potato milk.– Eggs do not contain casein.– Avoid foods that contain Casein: milk, yogurt, cheese, ice cream & pudding.Vitamin & Mineral Supplements:- If a diet is high in overly processed foods, a person may be deficient in vitamins C, E, B6 & minerals such as magnesium, molybdenum, chromium & selenium.
ASD OutcomeOutcomes are Variable: Ongoing problems with independent living, employment, social relationships & mental health.Predictors of Better Outcome:– Earlier Age of Diagnosis & Treatment.– No Cognitive Impairment.– Early Language & Nonverbal Skills.– Social Skills.
ConclusionAUTISM: A Complex Developmental Disability.Severity: The Most severe neuropsychiatriccondition in childhood.Typically appears during the first three years of life.Triad of impairments: Socialization, Communication& Imagination.Management Goals: Minimize core & associateddeficits, Maximize functional independence & QOL& Alleviate family stress.